Post-Acute Transitional Care Manager

POSITION DESCRIPTION:

The Post-Acute Transitional Care Manager is an integral member of the ambulatory care team.  This position is responsible for complex care management for patients in hospitals and post-acute care settings including, but not limited to, skilled nursing facilities, long-term care hospitals, inpatient rehabilitation facilities, home health agencies and patients’ homes in multiple counties in Southeast Michigan. Specific focus on patients requiring care in a Skilled Nursing Facility (SNF) is noted, as well as the dedication to providing in-person, on-site evaluation and care management. Duties will include transitional care assistance, coordination of continuing care, education and advocacy for patients in the post-acute care setting and transition back to their home.  The Post-Acute Transitional Care manager will provide communication and collaborate with the patient’s primary care office and specialists, as appropriate.

ESSENTIAL JOB FUNCTIONS:

1. Coordinates the care delivered and assists as needed with individualized patient interventions to minimize avoidable rehospitalizations for patients (and family) transitions, being admitted, discharged and transferred across the care continuum.
2. Develops a cohesive and strong team-oriented relationship with physicians, nurses and other healthcare professionals within the post-acute care setting to ensure the delivery of quality, efficient, patient centered and cost-effective healthcare services.
3. Obtains a thorough assessment of the patient which includes medical history, current clinical status, family and caregiver support and social determinants of health.
4. Assesses the family's knowledge base, expectations and the ability for a family member to act as the primary caregiver, if appropriate.
5. Assists the individual, the family and team, in identifying the variables that may influence the accomplishment of goals.
6. Establishes realistic and patient-centered short-term and long-term goals with the individual and family, reassessing progress and revisions periodically.
7. Responsible for establishing the patient care plan in collaboration with the patient and interdisciplinary care team which includes the treatment plan, disposition, progress, anticipated needs and expected length of stay. 
8. Promotes effective communication among the healthcare team members, including the patient, family, interdisciplinary team, case managers and primary care physician.
9. Advocates for the most appropriate, cost effective, evidence-based services to assure quality of care and attainment of appropriate goals. Recommends and coordinates home assessment services before discharge when appropriate.
10. Intervenes promptly when necessary to promote optimal functioning and prevention of complications.
11. Coordinates appropriate resources and supportive services to meet the patients’ needs at the time of transition to next level of care, based on collaboration with the healthcare team recommendations.
12. Provides verbal and written education to the individual and family regarding diagnosis, symptom management, community resources and supportive services.
13. Other duties as assigned.

Essential Job Functions Specific to Home Visits:

1.  Assures a medication reconciliation is completed at the time of discharge along with education and teach back with the individual/family based on who will be administering medications at next level of care.  This includes access and availability of obtaining medications. 
2. Completes home visits to facilitate a smooth transition back home, to include but not limited to a comprehensive assessment, home safety evaluation, and caregiver assessment.
3. Participates in virtual visits with PCP when appropriate, communicating new symptoms or concerns with PCP and updating of plan of care with the patient.
4. Completes Advanced Care Planning discussion with the patient and family with the goal of completing patient advocate documentation.
5. Discusses additional team resources available to the patient and refers appropriately to care management, dietitian, and pharmacy services. 
6. Facilitates hospital follow up visits to ensure patient sees primary care physician which can be in person or virtually.
7. Identifies and transitions patients requiring ongoing care management services to the practice care manager.

Essential Job Functions Specific to Skilled Nursing Facility:

1. Assists and supports patients during their transition to a post-acute care setting, through the rehabilitation process and then transition to the next level of care. 
2. Participates in conferences that provide ongoing evaluation of interprofessional dynamics, goal attainment, expected length of stay and treatment plan revision.
3. Serves as a liaison between the patient, physician, care team and the discharge planner by coordinating, monitoring and communicating the patient’s goals and progress, and assisting with coordination to the next level of care.
4. Facilitates and collaborates with the healthcare team for timely discharge planning to an alternate level of care or return to the individual’s previous level of care.
5. Directs discharge planning process in support of treatment adherence and medication compliance with specific focus on assisting transitions for patients discharged from an in-patient hospital to a skilled nursing facility.

ORGANIZATIONAL EXPECTATIONS:

1. Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the mission and values of Trinity Health Medical Group.
2. Must be able to work effectively as a member of the Clinical team.
3. Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
4. Successfully completes all relevant organizational training and adheres to Trinity Health Medical Group standard of care as outlined in the Trinity Health Code of Conduct.
5. Maintains knowledge of and complies with Trinity Health Medical Group standards, policies and procedures.
6. Maintains general knowledge of Trinity Health Medical Group  office services and in the use of all relevant office equipment, computer and manual systems.
7. Maintains strict confidentiality in compliance with Trinity Health Medical Group  and HIPAA guidelines.
8. Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities.  Embraces new ideas and respects cultural differences.
9. Uses resources efficiently.
10. If applicable, responsible for ongoing professional development – maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.

MEASURED BY:

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.  Care Management Metrics including productivity and ACP education and completion, and others defined by program.

ESSENTIAL QUALIFICATIONS:

EDUCATION:  Bachelor of Science degree in Nursing required; Master of Science degree in Nursing is preferred.  Completion of self-management support training preferred.

CREDENTIALS/LICENSURE:  Valid, unrestricted RN license in the State of Michigan; Valid CPR certification. CCM certification preferred, or completed within 2 years.

MINIMUM EXPERIENCE:   3-5 years of experience with primary care/ambulatory care, home health agency, skilled nursing facility or hospital medical-surgical, within the past five years. Care management experience preferred. Experience as participant in continuous quality improvement preferred.

POSITION REQUIREMENTS (ABILITIES & SKILLS):

1. Knowledge of patient care procedures and organizational policies related to position responsibilities.
2. Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment and patient education.
3. Knowledge of the compliance and quality aspects of clinical care and patient privacy and best practices in medical office operations.
4. Excellent assessment and triage skills (per specialty population expectations). Understands chronic disease management strategies and can implement appropriate protocols and guidelines.
5. Proficient/knowledgeable in medical terminology.
6. Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records and other care management and/or clinical IS systems, email, e-learning, intranet, Microsoft Word and Excel, and computer navigation needed to complete the tasks of clinical care and performance reporting.  Ability to use other software as required while performing the essential functions of the job.
7. Excellent communication skills in both written and verbal forms, including proper phone etiquette.  Ability to speak before groups of people, either in-person or virtually.
8. Ability to work autonomously and collaboratively in a team-oriented environment, displays courteous and friendly demeanor.
9. Ability to work effectively with various levels of organizational members and diverse populations including IHA and Hospital staff, providers, provider leadership, patients, family members, insurance carriers, vendors, external customers and community groups.
10. Good organizational and time management skills to effectively juggle multiple priorities and time constraints.
11. Ability to exercise sound judgement and problem-solving skills.  Demonstrated skills with influencing and negotiating individual and group decision-making.
12. Ability to handle patient and organizational information in a confidential manner.
13. Ability to drive to other office/practice sites and meeting and training locations, as well as hospitals, post-acute care facilities and patient homes within several counties in Southeast Michigan.
14. Successful completion of IHA competency-based program within introductory and training period.